Provider Demographics
NPI:1487755500
Name:COOPER, VICKIE LEE (PTA)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:LEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:VICKIE
Other - Middle Name:LEE
Other - Last Name:EGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:414 NORTHVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-1992
Mailing Address - Country:US
Mailing Address - Phone:262-670-8335
Mailing Address - Fax:
Practice Address - Street 1:2607 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:262-548-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI324-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40440200Medicaid